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Psychotherapy within a day-hospital or inpatient setting: the strength of a therapeutic milieu

Jaap Segaar

Anna Bartak

Frans Kamsteeg

Theo Ingenhoven (chair)

Invited symposium: IFP 2018, June 9

podium klinische psychotherapie

Why this invited symposium?

• Dutch long tradition with inpatient psychotherapy

• Number of beds decreased dramatically past decade

• Increase of outpatient EBM psychotherapies:

“Big Four” (DBT, TFP, SFT, MBT) ………and others

• But…not everywhere available, exclusion criteria, long

waiting lists (> 1 year), limited effect sizes, high dropping

out, high pushing out, psychotherapeutric side effects,

psychiatric decompensations…

• Question is: (for whom?) do we need more (expensive?)

intensive psychotherapeutic programs? Why should we

willing to pay for it?

Necessity for intensive psychotherapy:

from which perspective???

• Patients health perspective (patient/relatives)

• Treatment program perspective (therapist/team)

• Organization perspective (hospital staff/management)

• Scientific perspective (research department/PhDs)

• National mental health perspective (government politics/

assurance companies policies, associations of health

care professionals)

Patients (and their relatives) interests

• Fast an smooth reference

• Appropriate assessment & case conceptualization

• Personalized approach:

• strait forward treatment allocation (matched care)

• to an evidence based treatment program

• with competent therapists (treatment team)

• with no waiting lists: direct access

• in appropriate dosage (intensity and length)

• regular evaluations with flexible adjustments

• carefully planned termination

• appropriate available aftercare (whenever necessary)

Patients (and their relatives) interests

• Smooth reference

• Appropriate assessment & case conceptualization

• Personalized (integrative) approach

• Strait forward treatment allocation (matched care)

• To an evidence based treatment program

• With competent therapists (treatment team)

• With no waiting lists: direct access

• In appropriate dosage (intensity and length)

• Regular evaluations with flexible adjustments

• Carefully planned termination

• Appropriate available aftercare (whenever necessary)

Therapists (and team) interests

• Patients fitting therapists favorite treatment model

• Within therapists competence and specialization

• Specific registrations and accredited schooling

• Appropriate references to treatment by others

• Adequate production and financial income

• Low administration tasks

• Nice colleagues and inspiring intervision sessions

• Good salary; beautiful Christmas present

• Not to much night shifts

• Spacious training budget + freedom to choose

• Lots of spare time and exiting holidays

Therapists (and team) interests

• Patients fitting therapists favorite treatment model

• Within therapists competence and specialization

• Specific registrations and accredited schooling

• Appropriate references to treatment by others

• Adequate production and financial income

• Low administration tasks

• Nice colleagues and inspiring Intervision sessions

• Good salary; beautiful Christmas present

• Not to much night shifts

• Spacious professional training + freedom to choose

• Lots of spare time and exiting holidays

Organizational (management) interests

• Optimal mix of competent therapists (limited investments)

• Sufficient references towards programs (production)

• Waiting lists (but not too long); beds in use

• enough drop-outs (= initial DBC’s), but not too much!

• Satisfied external quality requirements

• Adequate client satisfaction feedback

• ROM & benchmark

• E-health (blended care)

• Satisfactory purchase by health care insurances

• No incidents (aggression, suicides); no complaints

Organizational (management) interests

• Optimal mix of competent therapists (limited investments)

• Sufficient references towards programs (production)

• Waiting lists (but not too long); beds in use

• enough drop-outs (= initial DBC’s), but not too much!

• Satisfied external quality requirements

• Adequate client satisfaction feedback

• ROM & benchmark

• E-health (blended care)

• Satisfactory purchase by health care insurances

• No incidents (aggression, suicides); no complaints

Scientific and scholar interests

• More and larger research grands

• High patient selections (Homogeneity ->exclusion criteria)

• Informed consent and randomization (RCT)

• High N for acceptable power (statistical significance)

• Straightforward classification (SCID-5; BPDSI…..)

• Validated assessment procedures

• No drop-outs

• Methodological & high tech ICT services

• Articles accepted in (high impact factor) journals

• High scientific and scholar status (Top-referent; Nobel

price)

Scientific and scholar interests

• More and larger research grands

• High patient selections (Homogeneity ->exclusion criteria)

• Informed consent and randomization (RCT)

• High N for acceptable power (statistical significance)

• Straightforward classification (SCID-5; BPDSI…..)

• Validated assessment procedures

• No drop-outs

• Methodological & high tech ICT services

• Accepted articles in (high impact factor) journals

• High scientific and scholar status (Top-referent; Nobel

price)

Mental health policies

• Market economy with competition

• Cost-benefit analysis and control

• Less expensive inpatient care beds

• Sound outpatient mental health system

• Lay man’s help (buurvrouw aan de keukentafel)

• High Qualies & society willingness to pay

• No weird people in the streets

• Less violence

• Less murders

• Zero suicides

Mental health policies

• Market economy with competition

• Cost-benefit analysis and control

• Less expensive inpatient care beds

• Sound outpatient mental health system

• Lay man’s help (buurvrouw aan de keukentafel)

• High Qualies & society willingness to pay

• No weird people in the streets

• Less violence

• Less murders

• Zero suicides

Which perspectives are we going to present:

Jaap Segaar: A milieutherapeutic approach in psychotherapeutic

treatment of personality disorders

Anna Bartak: Effectiveness of day-hospital and inpatient pychotherapy

for personality disorders: a systematic review on outcome research

Frans Kamsteeg: Positioning inpatient psychotherapy in the Dutch

mental health care system: from a single solution policy towards a

network framework perspective

Theo Ingenhoven: Rational treatment selection for personality disorders

in outpatient and (day)clinical settings: what is indicated for whom?

A milieutherapeutic approach

in psychotherapy treatment of

Personality Disorders.

Jaap Segaar

Not

"One model fits all"

Or

"One model fix all"

But:

"Personalized treatment"

Tailoring

Creative/Flexible

Embedded in:

Containing and holding environment

“Living learning” environment

Integrating:

(group)psychotherapy

experience based (art) therapies

social psychiatric support

skills training

system therapy

Integrated Modular Treatment

Combining Effective Treatment Methods

(John Livesley, 2017)

Historical overview

• Changing perceptions of madness:

Deviance as sin, deviance as crime,

deviance as sickness

• 'Golden age' of the asylum (1794 -1930):

1. Moral treatment of madness (“troubled

minds”)

2. Medical treatment of madness

(“diseased brains”)

• World War II

Therapeutic community: origins

• 1938 Army Psychiatric Services: Tavistock

Clinic, Northfield Hospital (Wilfred Bion, Tom

Main, Sigmund Foulkes)

• Maudsley Hospital, Mill Hill, Effort Syndrome

Unit, Henderson hospital therapeutic

community (Maxwell Jones)

Therapeutic community: origins

• Changing society and movement towards

more democracy

• Pressures produced by war (influx of

neurotic/psychosomatic patients, shortage of

staff, threats of ongoing bombing, etc.)

Therapeutic community: principles

Basic principles of therapeutic communities:

• Shared leadership by both patients and

staff (democratic principle)

• Decision-making at all levels

• Consensus in decision-making

• Two-way communication at all levels

• Social learning by social interaction here-

and-now.

(Jones, 1953)

Therapeutic community: pioneering

During the sixties and seventies multiple TC

were founded in The Netherlands,

pioneering in inpatient groupwork: Ideological phase

De Spiegelberg Jozef

Amstelland De Oosthoek

De Viersprong

Veluweland

Therapeutic community: survival?

(Day-)Clinical Psychotherapy

Integrated Modular Treatment

Combining Effective Treatment Methods

(John Livesley, 2017)

Clinical Psychotherapy: nowaday

• Integrated Treatment Program, high dosage, with

'common factors' as well as 'individually tailored

modules' targeting specific problems.

• Embedded in an "living learning" and

psychotherapeutic environment/milieu that is focusing

on social roles, social skills and interpersonal

interaction

• Within this overall framework, different “theoretical

working models" can be used, such as MBT, SFT,

TFP, DBT, APhT or TA

Clinical Psychotherapy: nowaday

• Combining different treatment modalities

(verbal therapy & experience-based therapy

& learning skills)

• Time limited (between 3 and 12 month)

• Using treatment contract as focus of

treatment

Common features

• Clear structure

• Integration

• Consistency

• Continuity

• Personaly attuned

• Goal-directed

• Targetting motivational and commitment issues

• Handling crises

• Promoting reflection on one’s own thoughts and feelings

• Involving family and other relevant people

Therapeutic milieu for PD patients

• An organized treatment unit in which a client is

offered space to shape relationships with other

clients, groups, practitioners, the department and/or

the institute.

• These relationships offer the client opportunities,

within its possibilities and limitations, to find new

solutions to its problems and to develop more

adaptive behavior patterns.

(Janzing & Kerstens, 1997)

Treatment process

self-actualization

(adaptive)

Actualisation of pathological themes

(disadaptive)

Treatment program

• Living environment

• Patient-staff-meeting (27 patients + staff)

• Sociotherapy (9 patients)

• Grouppsychotherapy (9 patients)

• Art-therapies: Creatieve therapie, Psycho MotorTherapy, Musictherapy, Psychodrama

• Skills training

• Systems therapy

• Farmacotherapy

Thank you for your attention

Bad weather: who is to blame?

Different stories about inpatient psychotherapy

Frans Kamsteeg, Directeur Specialismen GGNet

Paradox

• Evidence for effectiveness

• Difficult position in institutions for

mental healthcare

• What’s the logic?

Contexts

• Government

• Healthcare Insurers

• Boards of Mental healthcare

Institutions

• Professionals and researchers

Government

Mental Healthcare

Healthcare Insurers

• Simplification of complexity

• Just look at a period of 1 year

• Average price per single insured

patient

• Use of beds in bed-days

• New patients

Institutions

• No more growth in healthcare costs

• No business as usual

• Choices based upon criteria insurers

Inpatient psychotherapy

• Average price

– € 100.000,- vs. € 7.500,-

• Use of beds

– Long and stable vs. Short and decreasing

• New patients

– Few relative to total number (50 vs.

16.000)

• Not very popular

Professionals and researchers

• Convinced

• But not sure

• Oriented on own programs

• Knowing that patients in other

programs could profit from knowledge

and expertise

• What will the future look like (if not

the same)?

What to do?

• Accept the logic of the current system

• Create a new storyline to get a

different assessment:

– Lifetime perspective on patientlevel

– A networkperspective by organising

collaborative care, work from your

knowledge base

Rational treatment selection for personality disorders

in outpatient and (day)clinical settings:

what is indicated for whom?

Theo Ingenhoven, psychiatrist

Arkin, Amsterdam

theo.ingenhoven@npsai.nl 44

IFP 9 June 2018

Indication for treatment

“ What treatment,

by whom,

is most effective for this individual

with that specific problem,

under which set of circumstances ?”

Paul, 1967

In search of patient characteristics that may guide empirically based

treatment selection for personality disorder patients.

A concept mapping approach

• Systematic review literature: 310 variables

• Selection by experts: 81 variables

• Conceptmapping: 8 clusters

• Interpretation by 29 Dutch experts

Van Manen, Kamphuis, Goossensen, Timman, van Busschbach & Verheul

Journal of Personality Disorders, 2012, 26, 481-497

Concept mapping of indicators for treatment allocation in patients with

personality disorders

Van Manen, Kamphuis, Goossensen, Timman, van Busschbach & Verheul

Journal of Personality Disorders, 2012, 26, 481-497

Strength

Vulnerability

Concept mapping of indicators for treatment allocation in patients with

personality disorders

Van Manen, Kamphuis, Goossensen, Timman, van Busschbach & Verheul

Journal of Personality Disorders, 2012, 26, 481-497

Individual

Context

Concept mapping of indicators for treatment allocation in patients with

personality disorders

1. Severity of symptoms (distress) Depression, anxiety, psychotic symptoms, self harm, suicidality

2. Severity of personality pathology

Structural personality organization, severity personality disorder, maladaptive traits

3. Ego-adaptive capacities

Ego strength, identity integration, secure attachment, mentalizing capabilities

4. Motivation and working alliance

problem recognition, commitment, responsibility for own treatment, therapy allegiants, willingness, trust

5. Social functioning

Work, education, family, network, support system

6. Social demographic characteristics

Age, gender, living situation, finance

7. Trauma (past and present)

Physical and sexual abuse, emotional neglect, divorce parents, losses, being bullied

8. Treatment history and medical condition

Effect of former treatments, pharmacotherapy, dropping out, somatic problems tat interfere

Van Manen et al. (2012)

Concept mapping of indicators for treatment allocation in patients with

personality disorders

1. Severity of symptoms (distress) Depression, anxiety, psychotic symptoms, self harm, suicidality

2. Severity of personality pathology

Structural personality organization, severity personality disorder, maladaptive traits

3. Ego-adaptive capacities

Ego strength, identity integration, secure attachment, mentalizing capabilities

4. Motivation and working alliance

problem recognition, commitment, responsibility for own treatment, therapy allegiants, willingness, trust

5. Social functioning

Work, education, family, network, support system

6. Social demographic characteristics

Age, gender, living situation, finance

7. Trauma (past and present)

Physical and sexual abuse, emotional neglect, divorce parents, losses, being bullied

8. Treatment history and medical condition

Effect of former treatments, pharmacotherapy, dropping out, somatic problems tat interfere

Van Manen et al. (2012)

Individual

Context

Vulnerability

Strength

Strength

Vulnerability

Treatment allocation in patients with personality disorders

Conclusion I:

• The patient should be examined in terms of the amount of emotional pressure or stress she/he can tolerate and handle.

• Decide whether the patient needs a primarily stabilizing or supportive treatment (e.g. more like DBT) or, alternatively a more destabilizing or confrontational/expressive treatment (e.g. more like TFP).

• Expressive therapy is primarily focused at relational and conflictual issues by (cognitive and emotional) insight and emotional corrective experiences.

• A supportive approach is primarily focused on change by pacification and stabilization of the patients inner structure, by external support and structuring the environment.

Treatment allocation in patients with personality disorders

Conclusion II:

• Even more than outpatient psychotherapy, (day-)clinical psychotherapy can be classified as both supportive and expressive, both stabilizing and destabilizing within one program/milieu.

• Within the therapeutic milieu the amount of emotional pressure or stress can be handled carefully, also between sessions, within certain limits.

• More vulnerable patients need a more supportive and stabilizing (holding) environment than outpatient psychotherapy and the patients own context can offer.

• Moreover, interventions should also focus on systemic problems, such as family problems and lack of social support at home.

Treatment allocation in patients with personality disorders

Conclusion III: prevent iatrogenesis and non-response:

• All eight factors have to be carefully weighted since clinicians tend to focus to much on individual factors and underestimate the influence of context factors in treatment selection.

• Individual factors (both vulnerabilities and strengths) are important for case conceptualization and case formulation.

• Context factors (both vulnerabilities and strengths) are important screeners for available options for treatment selection and dosage.

• The eight clusters of patient and context characteristics can bring empirically based treatment selection a step closer.

Some thoughts on Demand of care

and dosage of treatment

Theo Ingenhoven

Demand of care & dosage

Severity/complexity

Dosage

Theo Ingenhoven

Most stakeholders think straightforward

and linear

Demand of care & dosage

Severity/complexity

Dosage

Outpatient 1x week

Outpatient 2x week

Outpatient plus

IHT

Inpatient crisis unit

General practitioner

Self-help/E-health

Theo Ingenhoven

Demand of care & dosage

Severity/complexity

Dosage

Outpatient 1x week

Outpatient 2x week

Outpatient plus

IHT

Inpatient crisis unit

General practitioner

Self-help/E-health

Theo Ingenhoven

Demand of care & dosage

Severity/complexity

Dosage

Theo Ingenhoven

Specialized outpatient psychotherapy

Day-clinical psychotherapy

Inpatient psychotherapy

FACT

Chronic care programs

General practicioner/POH

Basic outpatient mental health care

General practicioner/POH

Demand of care & dosage

Severity/complexity

Dosage

Theo Ingenhoven

Specialized outpatient psychotherapy

Day-clinical psychotherapy

Inpatient psychotherapy

FACT

Chronic care programs

General practicioner/POH

Basic outpatient mental health care

General practicioner/POH

MBT

Demand of care & dosage

Severity/complexity

Dosage

Theo Ingenhoven

Ambulant sGGz

Dagklinische psychotherapie

Klinische psychotherapie

Fact

SGGz of bGGz chronisch

Huisarts/POH

Ambulant bGGz

Symptom or problem focussed

Personality focussed

Recovery focussed

Psychotherapy within a day-hospital or inpatient setting: the strength of a therapeutic milieu

Jaap Segaar

Anna Bartak

Frans Kamsteeg

Theo Ingenhoven (chair)

Invited symposium: IFP 2018, June 9

podium klinische psychotherapie

Day-clinical and inpatient psychotherapy

• Represent an unique and (cost)effective EBM treatment

offer in treatment of personality disorders and comorbid

conditions.

• Can be carefully indicated for severe patients

• Can prevent deterioration into a chronic course (one-way

ticket out of psychiatry)

• Is indicated stepped care as well as matched care

• Main (political and ethical) question is: (for how long) are

we willing to pay for it?